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Conclusion: More stressful life events, more perceived mental strain of these events, ... of the addictive process is the stress-coping model (Wills & Hirky, 1996).

Procedia - Social and Behavioral Sciences 00 (2011) 000–000 Procedia - Social and Behavioral Sciences 30 (2011) 654 – 661

Procedia Social and Behavioral Sciences www.elsevier.com/locate/procedia

WCPCG 2011

The rate of various psychological stressors, perceived mental strain due to these stressors, and coping strategies in opium addicts compared to normal individuals Jafar Askaria, Afsaneh Hassanbeigia,b, Hossien Fallahzadehc* a

Department of Psychology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran b Mental Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran c School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

,1

Abstract Objective: The purpose of the present study was to determine the rate of stressful life events, the rate of perceived mental strain due to these stressors and various methods of coping with stress in opium addicts compared to normal subjects. Materials & Methods: 137 male addicts and 140 normal subjects matched for sex, age and education participated in present study. The instruments used included Paykel Scale of Stressful Life Events for assessing life stressors and the rate of perceived mental strain due to these stressors, and Billings and Moos Coping Checklist for assessing the methods of coping. The data were analyzed using Mann-Whitney Test. Results: The findings of the study showed that first, over a two-year period the occurrence rate of stressors related to illness and death of relatives, family problems, legal problems, occupational problems and other personal problems in opium addicts was statistically higher than normal subjects. Second, compared to normal subjects, the rate of perceived mental strain due to stressors of illness and death of relatives, family problems, legal problems and occupational problems was statistically significant in opium addicts. Third, in comparison to normal subjects, the opium addicts made significantly more use of avoidance and emotional-focused coping while they made significantly less use of active-behavioral and problem-focused coping. Conclusion: More stressful life events, more perceived mental strain of these events, and more inappropriate and ineffective coping strategies in opium addicts may play a considerable role in their drug abuse tendency and their turning to relapse. Keywords: stress; stressors; mental strain; coping strategies; opium addicts

1. Introduction Stressful life events have historically played an important role in theories of drug dependence (Goldsmith, 1998). Stress has been a ubiquitous explanation for many illnesses, ranging from the physical problems like heart disease and gastrointestinal disorders to the emotional and behavioural problems like depression and substance use (Tate, McQuaid, & Brown, 2005). As noted above, stress may affect health by producing changes in behaviour. There is evidence that under high levels of stress, health-enhancing behaviour declines and health-threatening behaviour increases so people are more likely to engage in behaviours that increase the risk of illness and injury. For example * Jafar Askari. Tel.: +98-0351-8203410-7; fax: +98-0351-8202632. E-mail address: [email protected] 1877-0428 © 2011 Published by Elsevier Ltd. Open access under CC BY-NC-ND license. Selection and/or peer-review under responsibility of the 2nd World Conference on Psychology, Counselling and Guidance. doi:10.1016/j.sbspro.2011.10.127

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during periods of high stress, consumption of nicotine, alcohol, and other drugs may increase (Milgrom , & Burrow, 2001). Hymana et al. (2009) in their study showed that opioid dependent subjects experience higher levels of stress and report greater stress when compared to controls. Similar studies also showed that life stressors can increase risk of tendency toward drug in non-patients or drug abuse relapse in under-treatment addict patients (Wills, Vacaro & McNamara, 1992; Smith, Hodgson, Bridgeman, & Shepherd, 2003; Johnson & Pandina, 1991; Storr, Trinkoff, & Anthony, 1999; Muntaner, Anthony, Crum, & Eaton, 1995). On the other hand, a reasonably large body of literature has accumulated examining the relation between stresscoping and drug abuse (Wagner, Myers & McIninch, 1999). One of the most popular cognitive-behavioral theories of the addictive process is the stress-coping model (Wills & Hirky, 1996). From this perspective, substance use is viewed as a coping response to deal with general life stress that can function to reduce negative effect or increase positive effect. Stress refers to the problems or strains that people encounter throughout life, and coping refers to the behavioural or cognitive responses that people use to manage stress (Lazarus & Folkman, 1984). In comparison to other potential coping strategies, coping via substance use generally is regarded to be limited in effectiveness, as repeated use of substances is detrimental to physical and psychosocial well-being (Wills & Hirky, 1996). As noted above, stress-coping skills are relevant for coping with general life stress, and the goal of stress-coping is to maintain physical and psychosocial well-being. The majority of research in the area has utilized Lazarus and colleagues’ (Lazarus & Folkman, 1984) typology of stress coping that distinguishes between problem-focused coping strategies, which are directed at altering or removing a stressor, and emotion-focused coping strategies, which are directed at managing affective states associated with or resulting from the problem. Despite the situational specificity of the effectiveness of problem-focused and emotion-focused coping, a general finding in the substance use literature has been that individuals who routinely use problem-focused stress-coping strategies are less likely to develop and more likely to overcome substance use problems than the individuals who routinely use emotionfocused stress-coping strategies (Wills & Hirky, 1996). For example, Wills, McNamara, Vaccaro, & Hirky (1996) have found that adolescents who characteristically employ emotion-focused relief-oriented coping strategies are at greatest risk for developing substance use problems. Other researches also emphasize that the use of problemfocused strategies is associated with better adjustment to trauma and life stressors (Staiger, Melville, Hides, Kambouropoulos & Lubman, 2009, Votta & Manion, 2003). Billings and Moos (1981) identified three methods of coping in addition to problem and emotion-focused category : a) active-cognitive, understood as the management of assessing potentially stressful events; b) activebehavioural, as the observable efforts aimed at managing a stressful situation; and c) avoidance, as refusal to face a problematic or stressful situation. Finney and Moos (1995) found that adult individuals, who rely more on approach coping and less on avoidance coping, are less likely to develop substance use problems and experience greater success in recovery attempts if they do develop such problems. Similar results have been found in studies of alcoholics and drug abusers undergoing detoxification (Madden, Hinton, Holman, Mountjouris, & King, 1995, Hymana et al. 2009, Epstein, Botvin, Diaz, Toth, & Schinke, 1995, Belding, Iguchi, Lamb, Lakin, &Terry, 1996). The present study focused on three objectives. First, to determine whether the amount of the occurrence of stressful life events in the addicts is greater than that of normal subjects or not, and to determine the most frequently occurring stressful life events in the addicts compared to normal subjects. Second, to determine whether the amount of perceived mental strain from stressful life events in the addicts is higher than normal subjects or not, and to determine which stressful life events impose greater mental strain on addicts. Third, to determine whether stress coping methods in addicts are different from normal subjects or not, and enumerate the most frequently used methods by addicts. Based on the objectives above three hypotheses were formed: first, the amount of the occurrence of stressful life events in the addicts is greater than normal subjects. Second, the amount of perceived mental strain from stressful life events in the addicts is higher than normal subjects. Third, the stress coping methods of addicts are different from those of normal subjects. 2. Materials and Methods 2.1. Participants A total of 137 male addicts randomly selected from different addiction treatment centers in Yazd in addition to 140 normal subjects as control group participated in the present study. 52.5% of the patients have been addict for 1 2

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to 5 years and 47.5% of them for 5 years and more. The control group was selected from the addict's normal family members, friends and relatives. This group was matched with the addict group for age, education, marital and socioeconomic status. Characteristics of the both addict and control groups are presented in Table 1. Table 1. Socioeconomic characteristics of addict and control groups. Groups

Addict group

Control group

(%)

(%)

20-30

42.3

43.1

31-40

31.3

27.7

41-50

26.4

29.2

Primary & secondary school

49.6

38.6

High school diploma

29.9

32.9

Bachelor and higher

20.5

28.5

Single

38.7

35.8

Married

61.3

64.2

Characteristics Age

Level of education

Marital status

2.2. Measures 2.2.1. Paykel Scale of Stressful Life Events This instrument includes 61 life events (Paykel, Prusoff & Uhlenhuth, 1971). The questionnaire consists of stressors related to health, illness, work, education, finances, bereavement, legal matters, courtship engagement, family relations, change of residence, social relation and marriage. To facilitate the statistical analysis of the above stressors we classified them into 7 categories of illness and death of relatives, family, legal, occupational, financial, educational and other personal problems. The case subjects were required to determine the experienced stressors related to two years prior to their addiction. The control group subjects were asked to define their experienced stressors over the past two years. To measure mental strain of life events, although in the original scale the subjects were required to determine the amount of perceived mental strain of each stressor on a scale of 0-20, for more convenience, we used a 0-3 scale in which zero indicated no stress, 1 weak stress, 2 medium stress, and 3 severe stress. 2.2.2. Billings and Moos Coping Checklist The Coping Checklist was designed to examine the strategies people use to cope with crises (Billings & Moos, 1981). Respondents were asked to specify a crisis they had experienced and then answer 19 items about how they dealt with it using a yes/no response format. Items were categorized into three method (active behavioural, active cognitive, avoidant coping) and two foci of coping (problem and emotion focused) subscales. 2.3. Analysis The data were analyzed using Mann-Whitney Test.

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3. Results Regarding the first objective of the research the findings showed that the number of stressors experienced by the addicts over a two-year period prior to their addiction was statistically greater than the number of stressors experienced by the control subjects over the two past years (Table 2). These stressors included illness and death of relatives, family problems, legal problems, occupational problems and other personal problems. By the way, the observed difference in financial problems wasn't statistically significant. Exceptionally, the normal subjects experienced more stressors for educational problems which were statistically significant. Table 2. Difference in the number of stressors experienced by the addict group over two-year period prior to their addiction compared to stressors of normal subjects over the two past years. Groups Stressors

Addict group

Control group

M (SD)

M (SD)

P value

1.32 (1.03)

.75 (.89)

.0001

Family problems

.52 (.72)

.31 (.49)

.03

Legal problems

.88 (1.03)

.39 (.81)

.0001

Occupational problems

.98 (1.04)

.66 (.84)

.01

Financial problems

Illness and death of relatives

1.11 (1.01)

.98 (.95)

NS

Educational problems

.13 (.41)

.38 (.71)

.0001

Other personal problems

.80 (.86)

.40 (.71)

.0001

Regarding the second objective of the study, the amount of mental strain perceived by the addict subjects for stressors of illness and death of relatives, family problems, legal problems and occupational problems was statistically higher than that of the normal subjects (Table 3). For the stressors of financial and other personal problems the difference between the two groups wasn't statistically significant. Exceptionally, for the stressors of educational problems, the amount of mental strain perceived by the normal subjects was statistically higher than that of the addict group. Table 3. Difference in the amount of the perceived mental strain of various stressors in the addict group compared to normal group. Groups

Addict group

Control group

M (SD)

M (SD)

Illness and death of relatives

2.26 (1.07)

1.83 (1.26)

Family problems

1.37 (1.20)

1.03 (1.29)

.01

Legal problems

1.42 (1.41)

.67 (1.07)

.0001

Occupational problems

1.69 (1.31)

1.38 (1.25)

.05

Financial problems

1.97 (1.26)

1.94 (1.11)

NS

Educational problems

1.11 (1.27)

1.49 (1.18)

.01

Other personal problems

1.81 (1.26)

1.59 (1.26)

NS

Stressors

4

P value

.008

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Finally, regarding the third objective, the findings showed that the addicts group first, made significantly more use of avoidance strategies and emotion-focused coping methods, second, made significantly less use of activebehavioral and problem-focused coping methods. There was no statistically significant difference between the two groups in the active-cognitive method (Table 4).

Table 4. Difference in the amount of use of various stress coping methods in the two groups of addict and normal. Addict group

Control group

Coping methods

Groups

M (SD)

M (SD)

Active-Cognitive

4.67 (1.05)

4.78 (1.16)

P value

NS

Active-Behavioral

3.85 (1.20)

4.13 (1.27)

.04

Avoidance

3.83 (1.17)

2.32 (1.17)

.0001

Problem-Focused Coping

6.08 (1.47)

6.56 (1.46)

.003

Emotion-Focused Coping

6.27 (1.41)

4.68 (1.50)

.0001

4. Discussion The purpose of the present study was to determine whether the experienced stressors, the amount of perceived mental strain due to these stressors and stress coping strategies of opium addicts is different from normal subjects or not. Based on the first hypothesis of the research, the findings revealed that in the addict group, some important life stressors as illness and death of relatives, family problems, legal problems, occupational problems and other personal problems were statistically higher than that of the normal subjects. This obtained result is consistent with the findings of other studies (Goldsmith, 1998; Wills, Pierce & Evans, 1996; Frone, 2008; Wills, et al. 1992; Smith, et al.2003; Johnson & Pandina, 1991; Storr, et al.1999; Muntaner, et al.1995) showed that negative life events have been found to be a risk factor for drug abuse. These results provide support for both the stress-induced substance use and stress response dampening propositions of the tension-reduction hypothesis (Frone, 2008). Similarly, another study indicated that minor stress plays an important role in substance use through its impact on cravings (Ames & Roitzsch, 2000). In this study, patients who endorsed a greater overall number of daily stressors had a higher probability of experiencing cravings. The authors propose two possible hypotheses for this finding. First, individuals who experience a greater number of stressors may experience cravings because substance use has been associated with stressful minor life events since these individuals have used substances as a means of coping with these events in the past. This hypothesis is consistent with the tension reduction theory of substance abuse. An alternative hypothesis is that individuals who report experiencing a greater number of minor stressors may also experience cravings because they have a heightened attention to these stressful events, thereby influencing the number of cravings they experience. On the other hand, regarding second hypothesis of the present study, it seems that perceived mental strain due to stressful life events is an important factor in substance use. For example, in the study of Ames & Roitzsch (2000) both the number of stressful events the patient reported experiencing and the perceived severity of these events were found to be significant predictors of cravings. Even after the total number of minor life events was entered into the model, individuals who perceived minor stressors as being more stressful had a greater probability of experiencing cravings. This finding suggests that an affective component may play a significant role in the experience of cravings. That is, a common affective component or cognitive bias may lead these individuals to perceive minor 5

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stressors as more stressful and may also influence the likelihood that they will experience cravings. Tate, Brown, Unrod and Ramo (2004) believe that long-term stressors may provoke repeated exposure to negative affective states that frequently serve as the context of drug abuse relapse. Various evidence also showed that stressful life events were an strong predictor of affective problems including anxiety and depression (O’Connor, Rasmussen, & Hawton, 2010, Pine, Cohen, Johnson, & Brook, 2002, Fox, Halpern, Ryan, & Lowe, 2010, Friis, Wittchen, Pfister, & Lieb, 2002). It is important that we understand the ways in which affect and drug abuse interrelate. Generally, negative affectivity has been found to be a powerful predictor of adolescent substance use with regards to both initiation and frequency of use (Henderson, Galen, & DeLuca, 1998). High-risk individuals (i.e., those with a family history of drug and alcohol problems) have been shown to have heightened reactivity to negative emotion-arousing stimuli, as well as increased motivation to use following negative emotion-arousing situations (Randall & Cox, 2001). Commonly, this relationship is conceptualised as a two-part model in which individuals who experience greater levels of negative effect are at a higher risk of using drugs or alcohol as a coping mechanism (e.g., to improve mood or provide distraction from unpleasant feelings; Measelle, Stice, & Springer, 2006). In turn, once the individual develops physical dependence, their drug abuse is assumed to be primarily motivated by a desire to avoid negative affective states associated with withdrawal. This negative reinforcement model is perhaps the oldest and most widely studied model of addiction (Kassel et al., 2007). Work examining the impact of negative affective states on attentional processes suggests that such states may increase attentional biases toward cues associated with drugtaking (e.g., drug paraphernalia, situations where drugs are used). With repeated drug use, these cues are thought to acquire motivational salience, thereby allowing them to disproportionately capture attentional resources (Robinson & Berridge, 2000). Exceptionally, in normal group the experienced stressors for educational problems and the amount of mental strain perceived by them were significantly higher than that of the addict group. This fact indicates that educational problems are more frequent and more important stressors for normal individuals compared to addict patients. Based on the third research hypothesis, the findings demonstrated that the opium addicts used significantly more avoidance strategy and emotion-focused method to cope whit stressful life events and made less use of active behavioural and problem-focused coping method. This finding is also consistent with the results of other researches. For example in the study of Wagner, et al., (1999) adolescents who reported a greater reliance on avoidance stresscoping (an emotion-focused strategy) exhibited greater drug involvement, whereas adolescents who reported a greater reliance on problem focused stress-coping exhibited less drug involvement. In the stress-coping literature, avoidance coping is viewed as effective for managing short-term, uncontrollable stressors, but ineffective (and potentially maladaptive) for managing more enduring, controllable stressors (Folkman & Lazarus, 1991). It may be that at-risk adolescents indiscriminately use avoidance stress coping strategies without regard to the nature of stressors (this could be the result of problems in stressor appraisal and/or limitations in coping repertoires). Such individuals may find substance use inviting because it represents another avoidance strategy or because it temporarily alleviates stress resulting from the unsuccessful resolution of more enduring, controllable stressors. Some studies also suggest that a reliance on emotion-focused relief-oriented coping strategies increases the risk of developing drug abuse problems. Conversely, a reliance on problem-focused coping strategies may protect against the development of substance use problems (Wagner et al. 1999, Wills & Hirky, 1996 Votta & Manion, 2003). Our results also are consistent with previous findings published in both the adolescent (e.g., Wills, et al. 1996) and adult (Finney & Moos, 1995) literatures about the relations between substance use and stress-coping. Finally one of the models that make a modest attempt to understand this complex interaction between coping and substance use is the cognitive-behavioural model (Marlatt, 1996) of the relapse process (Maulik, Tripathi, & Pal, 2002). It posits if a person has adequate coping response and increased self-efficacy, there is decreased probability of relapse while facing a high-risk situation. If the person is unable to engage in effective coping responses at that time it leads to decreased self-efficacy, which in turn, leads to drug use. With the first use (lapse), the individual violates the qualifying edict of abstinence and an abstinence violation effect (AVE) results (Stephens, Curtin, Simpson, & Roffman, 1994). In summary, many results suggest that awareness of various cognitive and behavioural patterns of addict patients may serve as important targets for treatment interventions. In this context, stress reduction and improved coping 6

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